Provider Demographics
NPI:1073067583
Name:BENNETT-OTTO, ANNETTE
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:BENNETT-OTTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W532 ROME OAK HILL RD
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:WI
Mailing Address - Zip Code:53156-9729
Mailing Address - Country:US
Mailing Address - Phone:815-342-1364
Mailing Address - Fax:
Practice Address - Street 1:2717 N GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1672
Practice Address - Country:US
Practice Address - Phone:262-513-0700
Practice Address - Fax:262-513-0707
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8381-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner